Introduction
The peripheral retina is defined as the region of the retina extending anteriorly into the pars plana.
- The equator is typically denoted by the location of the vortex veins.
- Another key feature typically seen is the long ciliary nerves, which appears as a slightly white-yellow line on widefield fundus photography.
Dead Giveaways
Asteroid Hyalosis
Small yellow white spheres adherent to the vitreous fibrils
Composed of calcium and phosphorus or lipid
Patient is usually asymptomatic, but otherwise has floater-like symptoms
90% unilateral, presenting usually in >60y
Associated with diabetes mellitus and hypertension
Asteroid hyalosis from the anterior view
Microcystoid Degeneration
Known as peripheral cystoid degeneration (usually superiorly and inferiorly)
Cysts and retinal thickening peripherally from the ora serrata, extending no further than the equator
Cysts appear in the INL and OPL
They are benign, but may coalesce to form retinoschisis
Can appear like drusen
White Without Pressure (WWOP)
Commonly seen in myopes
Grey-white translucent areas of the retina, often with a red-brown border which eventually transforms into DWOP
OCT shows increased EZ reflectivity
A benign lesions that can change and also move overtime
Thought to be due to changing vitreoretinal interface, or potential abnormal reflectivity.
Shows the red-brown border and the WWOP
Dark Without Pressure (DWOP)
Areas of darker retina with well defined edges that are usually scalloped
OCT shows increased EZ reflectivity as well
It is also a benign lesion that can change overtime, move overtime and disappear overtime.
Shows the dark zone with scalloped border
Pavingstone (Cobblestone) Degeneration
Round oval areas of chorioretinal atrophy which coalesce overtime
Occlusion of a single choriocapillaris lobule can lead to RPE and PR death
Due to the strong adhesion of the retina to the choroid, there is no risk of retinal breakage, and hence is benign
Sometimes can be associated with pigmentation (chronicity)
Shows the patchy atrophy, but also regions of RPE and PR death
Peripheral Drusen
Drusen found most commonly in the mid-peripheral retina usually in the superior/temporal quadrants
May have pigmentation
Increased prevalence with age, and potentially associated with AMD
Mid-peripheral drusen. Mainly in temporal region
Reticular (Honeycomb) Degeneration
Hyper-pigmented lines giving a net-like appearance in the peripheral retina (honeycomb polygon)
May be a differential for retinitis pigmentosa due to the pigmentary changes similar to bone spicules
Is bilateral in nature, often accompanied by peripheral drusen
Occur in approximately 20% of people over 40
Is very similar to the bone spicules seen in retinitis pigmentosa
diagnostic features
Normal Features of the Peripheral Retina:
Dentate Processes
Some areas of retina which extends into the pars plana
The oral bay is the tooth like structure, and the region in between the "teeth" are dentate processes
Oral Bays
Small island of pars plana surrounded by retina due to the meeting of two adjacent dentate processes. Shown above.
Most commonly found in the horizontal meridian, around 3 or 9 o'clock
Increases risk of retinal breaks at posterior edge with PVD
4% have enclosed oral bays, 0.6% have partially enclosed oral bays
Oral Pearls
Drusen-like structures at the junction of the retina and ciliary processes/along dentate processes
Located between RPE and Bruch's membrane
20% of eyes
Wright L et al. 2016. Shows the pearls along the dentate processes
Meridional Folds
Radial ridge of elevated retinal tissue oriented perpendicular to the ora serrata
Grey-white in colour
Present in 16-28% of eyes, often bilaterally
Affects all retinal layers, suggesting small retinal holes may develop due to vitreo-retinal traction
Shows the meridional fold 
OCT displays affects and folded retina, with potential hole formation
Diagnosis of Exclusion:
WWOP and DWOP must only be diagnosed when there are no other features which can explain the phenomena